Wake Forest launches digital health program for post-discharge stroke patients


The COMPASS-CP program, accessible through a hospital’s EHR platform, brings together healthcare providers, patients, their families and other participants to create a care management plan that includes remote monitoring of patients, medication and resource management to address the social and functional determinants of health.

Atrium Health Wake Forest Baptiste has joined the Wake Forest University School of Medicine develop and launch a digital health platform to improve the coordination and management of care for stroke patients after discharge from hospital.

COMPASS-CP (COMprehensive Post-Acute Stroke Services – Care Plan)accessible through the electronic health record platform, brings together a variety of resources, including remote patient monitoring services, wearable devices, virtual care, medication management services, and algorithms identifying social determinants and functions relevant to health.

The program aims to facilitate stroke care and recovery outside the hospital on a single platform, bringing together not only care teams, but also patients and their families, therapists, pharmacists and even social workers.

According to the health system’s website, the program “is a patient-centered electronic application that captures the social and functional determinants of an individual’s health at the point of care. Designed to be administered by a clinician in a clinical or home setting, the tool also assesses caregiver capabilities and essential resources for patients during the post-stroke care period. Hosted as a web or iPad application, the Functional Assessment is simple to administer, yet provides a comprehensive overview of potential barriers that may impede a patient’s ability to manage their personal health and recovery. »

“COMPASS-CP enables clinicians to securely receive and easily interpret remote monitoring data, such as blood pressure and physical activity, helping them, their patients and coaches make timely decisions and adjustments to lifestyle behaviors and medications aimed at reducing the likelihood that patients will suffer future strokes,” Pamela Duncan, Ph.D., professor of neurology at Wake Forest University School of Medicine, said in a press release. “This is a great example of how our academic learning health system can take research findings and develop solutions to help improve patient health here at home and across the country. “

The program is supported by the results of the huge COMPAS study, launched in 2015, which tested a digital healthcare model on approximately 3,000 patients at 41 North Carolina hospitals and compared the results to 3,000 patients receiving traditional care after hospital discharge. The study was supported by a five-year, $14 million grant from the Patient-Centered Outcomes Research Institute (PCORI).

To help introduce the program to other health systems, Wake Forest Innovations helped launch Care Directions, a start-up targeting the stroke care space.

Officials say the program could position participating healthcare systems for value-based care incentives from the Centers for Medicare & Medicaid Services, and eventually be expanded and expanded to other settings, such as primary care sites and sub-specialty, and chronic diseases.

Eric Wicklund is the innovation and technology editor for HealthLeaders.

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